PCR Auditing

Skills Clinic

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2015-2016 Program Materials

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PCR Auditing Skills Clinic Master Checklist

A001 A002 A101 A102 A201 Demographic Information

Operational Information

Scene Survey

HPI/CC

Medical History

Physical Exam

Interventions

Vital Signs

Non-emergency Transports

N/A N/A

Interfacility Transports

Emergency Transports

N/A

N/A

N/A

Air Ambulance Transports

Clin

ical

Info

rmat

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Add

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al D

ocum

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Req

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Sample Non-emergency PCR Audit Checklist

PCR Number: __________________ Date of Service: _______________ Transporting Crew: ______________________________________

The Crew Documented . . . YES NO Demographic Information

� Accurate Patient Name � Gender � Current Patient Address � Patient Date of Birth and Age � Patient Social Security Number � Patient Telephone Number � Patient Insurance Information

Operational Information � Dispatch Information

o Unit Identified o Dispatch Determinant/Code/Reported Patient Condition o Scene Location/Address

� Origin Information o Odometer Readings – Including Tenths o Zip Code

� Destination Information o Odometer Readings – Including Tenths o Facility Room Number/Dept., If Applicable o Rationale for Patient Destination

� Qualifying Signature Obtained – One of the Following: o Patient Signature, or o Signature and Relationship of Authorized Representative, and Documented

Physical or Mental Reason Patient Can’t Sign, or o If No Authorized Rep Available or Willing, Crew Documented Reason Patient

Can’t Sign, Signed Crew Statement at Time of Service, and Obtained Signature of Receiving Facility Representative at Time of Service

� All Crew Members Signed PCR – Including Typed/Printed Name and Level of Certification

� Was Medical Command Contacted – If So, Why and What Orders Issued? � Care Transferred to Who, When, and Where

Scene Survey � Location Type (i.e., Residence, Nursing Home, Hospital, Park, etc.) � Scene Safe to Enter – If Not, Why? � Patient’s Location on Scene (i.e., 5th Floor, Bedroom, Pool, etc.) � Patient’s Initial Position (i.e., Standing, Sitting, Laying, etc.) � Bystanders Present – If So, What Information Did They Provide?

Clinical Information – HPI/CC � Aside from transport, any chief complaints?

Clinical Information – Medical History � Allergies � Past Medical History � Past Surgical History � Medications (Dosage and Frequency)

o Prescription o Over the Counter o Supplements

Clinical Information – Physical Exam � Neurological / Musculoskeletal (Neuro/Musc.)

o Level of Consciousness o Demeanor o Motor Skills and Range of Motion in Both Upper and Lower Extremities o Bilateral Grip Strength and Pedal Push/Pull o Ambulatory Status

� Head, Eyes, Ears, Nose, Throat (HEENT) o Pupillary Response o Mucous Membranes

� Cardiovascular (CV) o Pulses Assessed, Including Rate, Rhythm, and Quality o Capillary Refill o Edema Location and Severity o Existing Access, such as Fistula, IV, Central Line, MedPort, etc., Including Site

Appearance and How Access was Secured o Medications Infusing, Including Dosage, Concentration, and Total Volumes

Infused � Respiratory (RR)

o Lung Sounds in All Lobes o Breathing Rate, Including Rhythm, and Work of Breathing o Chest Rise o Ventilator and Ventilator Settings

� Abdomen/ Genitourinary/Gastrointestinal (Abd./GI/GU) o Physical Exam o Bowel Sounds o I&O o Method of Output (i.e., Foley, Bedpan, etc.)

� Integumentary Skin o Temperature o Color o Moisture o Turgor o Ulcers o Dressings/Wound Vac

Clinical Information – Interventions � Repositioned for Comfort � How was Patient Transferred to Stretcher � Monitored Airway, Breathing, Circulation � Monitored EKG � Monitored Medication Infusion

Clinical Information – Vital Signs � Heart Rate � Blood Pressure � Respiratory Rate � Temperature � SpO2 � EtCO2

Additional Documentation Requirements for Non-emergency Transports � Complete Physician Certification Statement (PCS) Obtained (Including Valid Signature of

an Authorized Signer) � Crew Documented Whether or Not Patient was Able to:

o Ambulate o Sit in a Chair or Wheelchair and o Get out of Bed Without Assistance

� Crew Documented other physical or medical conditions that warrant ambulance transport (regardless of bed confinement)

PCR Reviewed By: ________________________ Date of Review:_____________________ Next Action: � Crew Query Rationale:___________________________________________ � Send to Supervisor Rationale:___________________________________________ � Send to Medical Director Rationale:___________________________________________

� Audit Passed; Submit to Billing Department

Sample Chest Pain PCR Audit Checklist

PCR Number: __________________ Date of Service: _______________ Transporting Crew: ______________________________________

The Crew Documented . . . YES NO Demographic Information

� Accurate Patient Name � Gender � Current Patient Address � Patient Date of Birth and Age � Patient Social Security Number � Patient Telephone Number � Patient Insurance Information

Operational Information � Dispatch Information

o Unit Identified o Dispatch Determinant/Code/Reported Patient Condition o Scene Location/Address

� Origin Information o Odometer Readings – Including Tenths o Zip Code

� Destination Information o Odometer Readings – Including Tenths o Facility Room Number/Dept., If Applicable o Rationale for Patient Destination

� Qualifying Signature Obtained – One of the Following: o Patient Signature, or o Signature and Relationship of Authorized Representative, and Documented

Physical or Mental Reason Patient Can’t Sign, or o If No Authorized Rep Available or Willing, Crew Documented Reason Patient

Can’t Sign, Signed Crew Statement at Time of Service, and Obtained Signature of Receiving Facility Representative at Time of Service

� All Crew Members Signed PCR – Including Typed/Printed Name and Level of Certification

� Was Medical Command Contacted – If So, Why and What Orders Issued? o If Following Standing Protocol, What Specific Protocol was Followed?

� Care Transferred to Who, When, and Where

Scene Survey � Location Type (i.e., Residence, Nursing Home, Hospital, Park, etc.) � Scene Safe to Enter – If Not, Why? � Patient’s Location on Scene (i.e., 5th Floor, Bedroom, Pool, etc.) � Patient’s Initial Position (i.e., Standing, Sitting, Laying, etc.) � Bystanders Present – If So, What Information Did They Provide?

Clinical Information – HPI / CC [OPQRST] � Onset - How the Pain Started � Provocation - What Causes the Pain and Factors that Increase / Decrease the Pain � Quality - Description of the Pain � Radiation - Where the Pain is Located � Severity - Pain Score and Scale (1-10 and/or Wong-Baker) � Time - When the Pain Started and How Long the Pain Lasts � Patient Interventions Prior To Arrival

o Home Medications o Over the Counter Medications o Repositioning o Contacted Doctor

Clinical information – Medical History � Allergies � Past Medical History � Past Surgical History

� Medications (Dosage and Frequency) o Prescription o Over the Counter o Supplements

Clinical Information – Physical Exam � Neurological / Musculoskeletal (Neuro/Musc.)

o Level of Consciousness o Demeanor o Bilateral Grip Strength and Pedal Push/Pull o Ambulatory Status o Pain and Pain Scale [OPQRST]

� Head, Eyes, Ears, Nose, Throat (HEENT) o Pupillary Response o Symmetrical Facial Muscle Tone

� Cardiovascular (CV) o Pulses Assessed, Including Rate, Rhythm, and Quality o Capillary Refill o Edema Location and Severity o Existing Access, such as Fistula, IV, Central Line, MedPort, etc., Including Site

Appearance and How Access Secured � Respiratory Exam (RR)

o Lung Sounds in All Lobes o Breathing Rate, Including Rhythm, and Work of Breathing o Chest Rise

� Abdomen/ Genitourinary/Gastrointestinal Exam (Abd./GI/GU) o Physical Exam o Bowel Sounds o I&O

� Skin Exam o Temperature o Color o Moisture o Turgor o Ulcers o Dressings/Wound Vac

Clinical Information – Interventions � IV Access (Including Gauge, Location, Method Secured, Success, Patency) � Medications (Including Method of Administration, Dosage, and Frequency)

o Total Volume of Fluids Infused � 3 lead EKG (Including Printout and Rhythm Interpretation) � 12 lead EKG (Including Printout and Rhythm Interpretation)

o Submitted to receiving facility

Clinical Information – Vital Signs � Heart Rate � Blood Pressure � Respiratory Rate � Temperature � SpO2 � EtCO2

Additional Documentation Requirements for Non-emergency Transports o Immediate Response o Lights and Sirens

PCR Reviewed By: ________________________ Date of Review:_____________________ Next Action: � Crew Query Rationale:___________________________________________ � Send to Supervisor Rationale:___________________________________________ � Send to Medical Director Rationale:___________________________________________

� Audit Passed; Submit to Billing Department

Mickey Mouse Ambulance

Patient Care Report

RUN NUMBER: A001 PATIENT NAME: Jack B. Nimble DATE OF SERVICE: 04/29/15

Times Response Information Mileage

CALL RECV’D 01:16

DISPATCH CODE Non-emergency transfer

TO SCENE 2.1

DISPATCH 01:16

RESPONSE PRIORITY BLS Cold (non-emergency)

ON SCENE 2.3

ENROUTE 01:17

LOCATION

Community Hospital 6467 Race St., Arendelle, 99918

ENROUTE TO DEST. 2.3

ON SCENE 01:26

TRANSPORTED TO

Medical Center 1 Magic Kingdom Way, Fantasyland 99916

AT DEST. 4.4

DEPART

SCENE 01:38 TRANSPORT

PRIORITY BLS Cold (non-emergency)

TOTAL LOADED

MILEAGE 2.1

ARRIVE DEST. 01:45 DISPATCH COMMENTS: None provided. Demographic

NAME Jack B. Nimble

DOB 11/12/1932

AGE 82

WEIGHT 120 lbs

ADDRESS 4216 Candy Lane, North Pole, 22222

SEX M

Initial Information CHIEF

COMPLAINT Cardiac PT FOUND In bed

MEDICAL HX

MEDICATIONS List

ALLERGIES NKDA

IMPRESSION Cardiac

Narrative

82 YOM, transfer to Medical Center for cardiac surgery care. Pt. rested comfortably during transport. VS monitored and documented below. No changes enroute.

Treatment Log

TIME

B/P

HR RR

SPO2 ETCO2

TEMP

EXAM (NEURO, RR, CV, ABD, SKIN)

TREATMENT (O2, MED, PIV, EXTRICATION)

01:39 128/P 94 16 96% Baseline

Crew Information

NAME Dopey Dwarf CERT# B-00765

LEVEL B

SIGNATURE Dopey Dwarf (e-signature)

NAME Happy Dwarf CERT# P-00978

LEVEL P

SIGNATURE Happy Dwarf (e-signature)

Mickey Mouse Ambulance

Patient Care Report

RUN NUMBER: A002 PATIENT NAME: Jackie B. Quick DATE OF SERVICE: 08/31/15

Times Response Information Mileage

CALL RECV’D

DISPATCH CODE Non-emergency transfer

TO SCENE

DISPATCH

RESPONSE PRIORITY BLS Cold (non-emergency)

ON SCENE 814.1

ENROUTE 09:24

LOCATION

15 Fairview Court Frontierland, 99913

ENROUTE TO DEST.

ON SCENE 09:30

TRANSPORTED TO

Dialysis Center 7878 Creek Run Road Frontierland, 99913

AT DEST. 817.1

DEPART SCENE

TRANSPORT PRIORITY BLS Cold (non-emergency)

TOTAL LOADED

MILEAGE 3.0

ARRIVE DEST. 09:50 DISPATCH COMMENTS: None. Demographic

NAME Jackie B. Quick

DOB 01/12/1954

AGE 61

WEIGHT

ADDRESS 15 Fairview Court, Frontierland, 99913

SEX F

Initial Information CHIEF

COMPLAINT No complaints; dialysis transport PT FOUND

Laying supine in hospital style bed on first floor of residence. Scene without any hazards.

MEDICAL HX ESRD, quadriplegia, CAD, MI

MEDICATIONS ASA, Nitro, Lasix

ALLERGIES Morphine

IMPRESSION Bed confined – see narrative

Narrative

Unit 4 dispatched to above address – dispatch/response times as noted. Pt. had no c/c as this was a scheduled non-emergency dialysis transport. Pt. was under care of live-in home health aide. We assumed care of pt. from this aide and followed the non-emergency transport protocol. ROS: Denies Neuro/MS, HEENT, CV, RR, GI/GU/Abd. issues. Does have a stage IV ulcer to coccyx. Exam: Neuro – CAOx3, GCS 15, pleasant/cooperative demeanor, CN grossly intact, no nuchal rigidity, absent motor skills related to quadriplegia in BUE and BLE. HEENT – Atraumatic, normocepahlic, pupils PERRL, symmetrical facial muscle tone, no JVD at semi-folwers position, trach midline, mucous membranes pink and moist CV – Radial pulses palpable and strong, regular, cap refill < 3 in both BUE and BLE. Dialysis fistula with palpable pulse. RR – Regular rate and rhythm, no increased work of breathing, equal chest rise, LS clear in all lobes. GI/GU/Abd – Distended, soft to touch, without tenderness/facial grimace. Skin – Pink, warm, dry, no tenting. Stage IV decubitis to coccyx – dsg. intact and without drainage. Dsg. dated 08/29/15. Due to quadriplegia, pt. required 2 man draw sheet transfer from hospital bed to stretcher. Pt. was secured and provided a sheet for comfort. Pt. secured in pt. compartment and transported to dialysis center. Treatments as noted below. Upon arrival at dialysis, pt. again required 2 man draw sheet transfer from stretcher to dialysis chair #5. Verbal report provided bedside to dialysis technician.

Treatment Log

TIME

B/P

HR RR

SPO2 ETCO2

TEMP

EXAM (NEURO, RR, CV, ABD, SKIN)

TREATMENT (O2, MED, PIV, EXTRICATION)

09:30 146/86 68 12 98% 98.6 F Noted in narrative. Exam.

09:35 - - - - - - To stretcher via 2 man draw sheet lift.

09:45 146/P 66 14 98% - VS; exam unchanged; pt. complaint free.

VS and reassess

09:50 - - - - - - At destination, transfer care.

Crew Information

NAME Hans Southern CERT# B-00369

LEVEL B

SIGNATURE Hans Southern (e-signature)

NAME Kristoff Anderson CERT# B-00123

LEVEL B

SIGNATURE Kristoff Anderson (e-signature)

Physician Certification Statement for Non-Emergency Ambulance Services

SECTION I – GENERAL INFORMATION

Patient’s Name: Jackie B. Quick Date of Birth: ___01/12/1954________ Medicare #:

Transport Date:08/31/15 (PCS is valid for round trips on this date and for all repetitive trips in the 60-day range as noted below.)

Origin: 15 Fairview Court, Frontierland 99913 Destination: Dialysis Center, 7878 Creek Run Road, Frontierland, 99913 Is the pt’s stay covered under Medicare Part A (PPS/DRG?) YES NO

Closest appropriate facility? YES NO If no, why is transport to more distant facility required?

If hosp-hosp transfer, describe services needed at 2nd facility not available at 1st facility:

If hospice pt, is this transport related to pt’s terminal illness? YES NO Describe:

SECTION II – MEDICAL NECESSITY QUESTIONNAIRE Ambulance Transportation is medically necessary only if other means of transport are contraindicated or would be potentially harmful to the patient. To meet this requirement, the patient must be either “bed confined” or suffer from a condition such that transport by means other than ambulance is contraindicated by the patient’s condition The following questions must be answered by the medical professional signing below for this form to be valid: 1) Describe the MEDICAL CONDITION (physical and/or mental) of this patient AT THE TIME OF AMBULANCE TRANSPORT that requires

the patient to be transported in an ambulance and why transport by other means is contraindicated by the patient’s condition: Pt. quadriplegic, unable to move any extremity, unable to brace self, poor trunk control. Pt. also has stage IV decubitis ulcer on

coccyx and is currently seeking treatment. First diagnosed 08/28/15. ____________________________________________

2) Is this patient “bed confined” as defined below? Yes No To be “bed confined” the patient must satisfy all three of the following conditions: (1) unable to get up from bed without Assistance; AND (2) unable to ambulate; AND (3) unable to sit in a chair or wheelchair

3) Can this patient safely be transported by car or wheelchair van (i.e., seated during transport, without a medical attendant or monitoring?)

Yes No 4) In addition to completing questions 1-3 above, please check any of the following conditions that apply*:

*Note: supporting documentation for any boxes checked must be maintained in the patient’s medical records Contractures Non-healed fractures Patient is confused Patient is comatose Moderate/severe pain on movement Danger to self/other IV meds/fluids required Patient is combative Need or possible need for restraints

DVT requires elevation of a lower extremity Medical attendant required Requires oxygen – unable to self administer Special handling/isolation/infection control precautions required Unable to tolerate seated position for time needed to transport

Hemodynamic monitoring required enroute Unable to sit in a chair or wheelchair due to decubitus ulcers or other wounds Cardiac monitoring required enroute Morbid obesity requires additional personnel/equipment to safely handle patient

Orthopedic device (backboard, halo, pins, traction, brace, wedge, etc.) requiring special handling during transport

Other (specify)

SECTION III – SIGNATURE OF PHYSICIAN OR HEALTHCARE PROFESSIONAL

I certify that the above information is true and correct based on my evaluation of this patient, and represent that the patient requires transport by ambulance and that other forms of transport are contraindicated. I understand that this information will be used by the Centers for Medicare and Medicaid Services (CMS) to support the determination of medical necessity for ambulance services, and I represent that I have personal knowledge of the patient’s condition at the time of transport.

If this box is checked, I also certify that the patient is physically or mentally incapable of signing the ambulance service’s claim and that the institution with which I am affiliated has furnished care, services or assistance to the patient. My signature below is made on behalf of the patient pursuant to 42 CFR §424.36(b)(4). In accordance with 42 CFR §424.37, the specific reason(s) that the patient is physically or mentally incapable of signing the claim form is as follows: quadriplegia Dr. M. Goose, MD, FACEP (e-signature) 08/30/15 Signature of Physician* or Healthcare Professional Date Signed (For scheduled repetitive transport, this form is not valid for

transports performed more than 60 days after this date). Dr. M. Goose, MD, FACEP (e-signature) Printed Name and Credentials of Physician or Healthcare Professional (MD, DO, RN, etc.) *Form must be signed only by patient’s attending physician for scheduled, repetitive transports. For non-repetitive, unscheduled ambulance transports, if unable to obtain the signature of the attending physician, any of the following may sign (please check appropriate box below): Physician Assistant Clinical Nurse Specialist Registered Nurse Nurse Practitioner Discharge Planner

This is a sample only and does not constitute legal advice. User bears all responsibility for compliance with all applicable laws and regulations.

Mickey Mouse Ambulance

Patient Care Report

RUN NUMBER: A101 PATIENT NAME: Cand L. Stick DATE OF SERVICE: 08/29/15

Times Response Information Mileage

CALL RECV’D 10:23

DISPATCH CODE Cardiac Arrest

TO SCENE

DISPATCH 10:23

RESPONSE PRIORITY ALS Emergency

ON SCENE

ENROUTE 10:24

LOCATION

669 Boneless Ave Fantasyland, 99916

ENROUTE TO DEST.

ON SCENE 10:29

TRANSPORTED TO

Medical Center 1 Magic Kingdom Fantasyland, 99916

AT DEST.

DEPART

SCENE 10:39 TRANSPORT

PRIORITY ALS Emergency

TOTAL LOADED

MILEAGE 3.5

ARRIVE DEST. 10:44 DISPATCH COMMENTS: Demographic

NAME Cand L. Stick

DOB 07/04/1912

AGE 103

WEIGHT

ADDRESS

669 Boneless Ave Fantasyland, 99916

SEX F

Initial Information CHIEF

COMPLAINT Cardiac Arrest PT FOUND In the care of the Fire Department

MEDICAL HX None Known

MEDICATIONS None Known

ALLERGIES

None Known

IMPRESSION Cardiac Arrest

Narrative

Dispatched Emergency by County to 669 Boneless Avenue, for a female in cardiac arrest with CPR in progress. AOS to find Fire Dept. already on scene performing CPR. HPI - Firefighter stated that the patient was found by home health aide on the floor, unknown downtime. No other information was provided or known. The crew did not access the residence – pt. brought to stretcher by FD first responders via longboard. PE - Pt is pulseless and apneic, Skin: warm, dry and pale, Pupils: 5 mm non reactive, (-) lividity (-) Rigor Mortis present, (-) petechiae noted around the eyes, (-) deformities (-) ecchymosis to chest or extremities, (+) slight gastric distension noted, (+) wet diaper. No obtainable vital signs. TX- ALS assessment completed, CPR in progress, placed the patient on cardiac monitor, 7.0 ET tube placed, confirmed tube placement via visualization of the cords and fog in the tube, IO placed in the Humerus, NSS, 3.0 mg EPI 1:10,000 IO. Transferred care to ER staff upon arrival at Little Hospital.

Treatment Log

TIME

B/P

HR RR

SPO2 ETCO2

TEMP

EXAM (NEURO, RR, CV, ABD, SKIN)

TREATMENT (O2, MED, PIV, EXTRICATION)

Crew Information

NAME Peter Pan CERT# P-00755

LEVEL P

SIGNATURE

NAME Tinker Bell CERT# P-00377

LEVEL P

SIGNATURE Tinker Bell (e-signature)

Mickey Mouse Ambulance

Patient Care Report

RUN NUMBER: A102 PATIENT NAME: Pail O. Water DATE OF SERVICE: 06/26/15

Times Response Information Mileage

CALL RECV’D

DISPATCH CODE BLS Fall

TO SCENE 0.0

DISPATCH 04:14

RESPONSE PRIORITY BLS Emergency

ON SCENE 2.9

ENROUTE 04:15

LOCATION

937 Danger St. Monstropolous 99917

ENROUTE TO DEST. 2.9

ON SCENE 04:21

TRANSPORTED TO

Medical Center 1 Magic Kingdom Way Fantasyland, 99916

AT DEST. 10.6

DEPART SCENE 04:31

TRANSPORT PRIORITY

BLS Emergency – Lights and Sirens

TOTAL LOADED

MILEAGE 7.7

ARRIVE DEST. 04:46 DISPATCH COMMENTS: Demographic

NAME Pail O. Water

DOB 08/23/1944

AGE 71

WEIGHT

ADDRESS

937 Danger St. Monstropolous 99917

SEX F

Initial Information CHIEF

COMPLAINT Fall PT FOUND Laying on basement floor

MEDICAL HX

Anxiety, DM, UTI, Seizure, Depression, Unknown CA

MEDICATIONS Dilantin, Klonopin, Xanax

ALLERGIES NKDA

IMPRESSION Fall

Narrative 911 dispatch for 71 yof that fell. Unit 3 responded. On scene, pt states “I tripped about halfway down the steps and fell the rest of the way.” Pt. states she can’t remember the last 30 minutes. Pt. states she now has back pain between her shoulder blades from the fall and requests evaluation for same. CMS x4 with no complaints, skin: warm dry and normal color. No interventions performed.

Treatment Log

TIME

B/P

HR RR

SPO2 ETCO2

TEMP

EXAM (NEURO, RR, CV, ABD, SKIN)

TREATMENT (O2, MED, PIV, EXTRICATION)

04:40 150/96 56 16 100%

Crew Information

NAME Sebastian Mon CERT# P-00823

LEVEL P

SIGNATURE Sebastian Mon (e-signature)

NAME Flounder Ing CERT# B-00046

LEVEL B

SIGNATURE Flounder Ing (e-signature)

Mickey Mouse Ambulance

Patient Care Report

RUN NUMBER: A201 PATIENT NAME: Jack N. Jill DATE OF SERVICE: 03/31/15

Times Response Information Mileage

CALL RECV’D

DISPATCH CODE Flight Transport

TO SCENE

DISPATCH 06:53

RESPONSE PRIORITY Flight

ON SCENE

ENROUTE 07:15

LOCATION

General Hospital 10 Atlantica View Rd Neverland 99915

ENROUTE TO DEST.

ON SCENE 07:20

TRANSPORTED TO

Medical Center 1 Magic Kingdom Way Fantasyland, 99916

AT DEST.

DEPART SCENE 07:53

TRANSPORT PRIORITY Flight

TOTAL LOADED

MILEAGE

ARRIVE DEST. 08:25 DISPATCH COMMENTS: Demographic

NAME Jack N. Jill

DOB 10/20/1941

AGE 74

WEIGHT 108 lbs.

ADDRESS

2014 First St. Arendelle 99918

SEX M

Initial Information CHIEF

COMPLAINT Altered LOC status post traumatic head injury PT FOUND ICU bed 6

MEDICAL HX None

MEDICATIONS None

ALLERGIES NKDA

IMPRESSION Critical care transfer

Narrative Arrived bedside. Pt. with increased confusion after hitting head then deteriorating mental status. Found pt. in semi-fowlers position in ICU bed. Implied consent. Pt unconscious and sedated on Propofol – withdraws to pain. Pupils unequal but reactive to light (left 5 mm, right 3 mm). Soft wrist restraints bilaterally – distal neurovascular intact. No spontaneous respiratory effort but coughs with deep suction. ETT, 7.0, 24 cm at lip line. EKG attached – showed NSR. IV and foley remain patent and secure. Cold load after both assessment and transfer of care from origin RN, hot off load at destination. Transfer to ICU bed 1 and report bedside. Followed flight protocols during transport. IVs: 20g, right a/c, secured with tape, 100 mL NSS infused; 18g, left a/c, secured with tape, patent Meds: Propofol, 20 mcg/kg/min via right a/c IV; Vent: SIMV, VT 450, rate 20, PEEP 5, Transported as pt. required ICU/neurosurgical services not available at origin.

Treatment Log

TIME

B/P

HR RR

SPO2 ETCO2

TEMP

EXAM (NEURO, RR, CV, ABD, SKIN)

TREATMENT (O2, MED, PIV, EXTRICATION)

07:25 192/89 66 V 100% Narrative Exam

07:35 176/88 66 V 100% Unchanged

08:00 166/89 62 V 100% Unchanged

08:15 146/69 64 V 100% Unchanged

Crew Information

NAME Sim Ba CERT# RN-005102

LEVEL RN

SIGNATURE Sim Ba (e-signature)

NAME Raph Iki CERT# RN-004102

LEVEL RN

SIGNATURE Raph Iki (e-signature)

Mickey Mouse Ambulance Signature/Claim Submission Authorization Form

Patient Name: Jack N. Jill Transport Date: 03/31/15 Privacy Practices Acknowledgment: by signing below, the signer acknowledges that Mickey Mouse Ambulance provided a copy of its Notice of Privacy Practices to the patient or other party with instructions to provide the Notice to the patient. *A copy of this form is valid as an original*

This is a sample only and does not constitute legal advice. User bears all responsibility for compliance with all applicable laws and regulations.

This is a sample o

This is a sample only and does not constitute legal advice. User bears all responsibility for compliance with all applicable laws and regulations.

Describe the circumstances that make it impractical for the patient to sign:

I am signing on behalf of the patient to authorize the submission of a claim to Medicare, Medicaid, or any other payer for any services provided to the patient by Mickey Mouse Ambulance now or in the past or in the future. By signing below, I acknowledge that I am one of the authorized signers listed below. My signature is not an acceptance of financial responsibility for the services rendered.

Authorized representatives include only the following individuals:

Patient’s legal guardian Relative or other person who receives social security or other governmental benefits on behalf of the patient Relative or other person who arranges for the patient’s treatment or exercises other responsibility for the patient’s affairs Representative of an agency or institution that did not furnish the services for which payment is claimed (i.e., ambulance services) but furnished

other care, services, or assistance to the patient X Representative Signature Date Printed Name of Representative

I authorize the submission of a claim to Medicare, Medicaid, or any other payer for any services provided to me by Mickey Mouse Ambulance now, in the past, or in the future, until such time as I revoke this authorization in writing. I understand that I am financially responsible for the services and supplies provided to me by Mickey Mouse Ambulance, regardless of my insurance coverage, and in some cases, may be responsible for an amount in addition to that which was paid by my insurance. I agree to immediately remit to Mickey Mouse Ambulance any payments that I receive directly from insurance or any source whatsoever for the services provided to me and I assign all rights to such payments to Mickey Mouse Ambulance. I authorize Mickey Mouse Ambulance to appeal payment denials or other adverse decisions on my behalf. I authorize and direct any holder of medical, insurance, billing or other relevant information about me to release such information to Mickey Mouse Ambulance and its billing agents, the Centers for Medicare and Medicaid Services, and/or any other payers or insurers, and their respective agents or contractors, as may be necessary to determine these or other benefits payable for any services provided to me by ABC, now, in the past, or in the future. I also authorize Mickey Mouse Ambulance to obtain medical, insurance, billing and other relevant information about me from any party, database or other source that maintains such information.

If the patient signs with an “X” or other mark, a witness should sign below.

X Patient Signature or Mark Date Witness Signature Date

___________________________________________________________ Witness Address

Describe the circumstances that make it impractical for the patient to sign: Pt. sedated, intubated Name and Location of Receiving Facility: Medical Center, 1 Magic Kingdom Way Time: 08:25 A signature below authorizes submission of a claim to Medicare, Medicaid, or any other payer for any services provided to the patient by Mickey Mouse Ambulance. A. Ambulance Crew Member Statement (must be completed by crew member at time of transport) My signature below indicates that, at the time of service, the patient was physically or mentally incapable of signing, and that none of the

authorized representatives listed in Section II of this form were available or willing to sign on the patient’s behalf. My signature is not an acceptance of financial responsibility for the services rendered.

X Sim Ba (e-signature) 03/31/15 Sim Ba, RN Signature of Crewmember Date Printed Name and Title of Crewmember

B. Receiving Facility Representative Signature The patient named on this form was received by this facility on the date and at the time indicated and this facility furnished care, services or

assistance to the patient. My signature is not an acceptance of financial responsibility for the services rendered.

X____Na La_(e-signature)________ __03/31/15__ ___Na La, ____________________________________ Signature of Receiving Facility Representative Date Printed Name and Title of Receiving Facility Representative

SECTION II - AUTHORIZED REPRESENTATIVE SIGNATURE Complete this section only if the patient is physically or mentally incapable of signing.

SECTION I - PATIENT SIGNATURE The patient must sign here unless the patient is physically or mentally incapable of signing.

NOTE: if the patient is a minor, the parent or legal guardian should sign in this section.

SECTION III - AMBULANCE CREW AND RECEIVING FACILITY SIGNATURES Complete this section only if: (1) the patient was physically or mentally incapable of signing, and

(2) no authorized representative (Section II) was available or willing to sign on behalf of the patient at the time of service.

Physician Certification Statement for Non-Emergency Ambulance Services

Section 2 - Medicare Definition of “Medical Necessity” for Ambulance Transportation:

Medicare covers ambulance services, including fixed wing and rotary wing ambulance services, only if they are furnished to a beneficiary whose medical condition is such that other means of transportation are contraindicated.

The beneficiary's condition must require both the ambulance transportation itself and the level of service provided in order for the billed service to be considered medically necessary.

Nonemergency transportation by ambulance is appropriate if either:

o The beneficiary is bed-confined, and it is documented that the beneficiary's condition is such that other methods of transportation are contraindicated; or,

o If his or her medical condition, regardless of bed confinement, is such that transportation by ambulance is medically required.

Thus, bed confinement is not the sole criterion in determining the medical necessity of ambulance transportation. It is one factor that is considered in medical necessity determinations.

For a beneficiary to be considered bed-confined, the following criteria must be met:

o The beneficiary is unable to get up from bed without assistance. o The beneficiary is unable to ambulate. o The beneficiary is unable to sit in a chair or wheelchair.

The medical necessity definition above appears exactly as it is contained in 42 C.F.R. § 410.40.

Section 3 - Certification

I certify that the medical necessity requirements set forth above for ambulance services are met.

Dr. Cru L. Deville (e-signature) 03/31/15 Signature of Physician* or Healthcare Professional Date Signed

Cru L. Deville, MD, PhD, MBA Printed Name and Credentials of Physician* or Healthcare Professional (REQUIRED)

*For scheduled, repetitive transports, this form must be signed by the patient’s attending physician. The physician’s order must be dated no earlier than 60 days before the date the service is furnished.

For non-repetitive or unscheduled transports, this form may be signed by one of the following if the signature of the attending physician cannot be obtained:

● Registered Nurse ● Discharge Planner ● Nurse Practitioner ● Physician Assistant ● Clinical Nurse Specialist

Section 1 – Patient Information

Patient Name: Jack N. Jill Date of Birth: 10/20/1941 Transport Date: 03/31/15

Run A201 Air Medical AOB.pdfMickey Mouse Ambulance Signature/Claim Submission Authorization Form